Healthcare Provider Details

I. General information

NPI: 1346643038
Provider Name (Legal Business Name): MADISON MEMORIAL HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/08/2014
Last Update Date: 10/24/2025
Certification Date: 10/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 E MAIN ST
REXBURG ID
83440-2048
US

IV. Provider business mailing address

PO BOX 130
REXBURG ID
83440-0130
US

V. Phone/Fax

Practice location:
  • Phone: 208-359-6419
  • Fax: 208-359-6915
Mailing address:
  • Phone: 208-359-6419
  • Fax: 208-359-6915

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number40
License Number StateID

VIII. Authorized Official

Name: RACHEL GONZALES
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: DM, RN, RODP
Phone: 208-359-6900